Category: Uncategorized

Understanding Medicare Reimbursement?

Dec 2, 2010

By HERBERT MATHEWSON, MD

I opened my “Medicare Summary Notice” from CMS (Centers for Medicare and Medicaid Services) with great anticipation to see the explanation of Medicare benefits for my recent medical care. At last, I might have a chance to understand Medicare reimbursement, an understanding that has to date eluded me both as a pediatrician and a hospital administrator

The ER physician’s bill for both the visit and the suturing of three lacerated fingers was $448.00. Medicare “approved” $163.88 and “paid” $131.10. It also stated that I could be billed the $32.78 difference, but I knew I wouldn’t because “balance billing” is not permitted in Massachusetts. A reminder that even though Medicare is a federal program, its reimbursements and reimbursement rules vary by state, by region, and even by county.

Then I noticed a small “a” in the last column to the right that instructed me to “See Note Section”. On the bottom of page 2 that little “a” in the Note Section told me that “Medicare paid the provider for this claim $197.81” a figure quite different than $131.10. I tried, but could not reach the new figure by adding up any of the other amounts. I had no clue as to where that number came from.

Moving on to the next encounter, a scheduled spinal tap in the Ambulatory Procedure Area of my hospital for a different clinical problem, I was surprised to run into more complexity. The hospital charged $697 for the procedure and $634 for the 6 lab tests done on the spinal fluid for a total hospital charge of $1,331.00. No “approved” amount nor “paid” amount was listed, but then I noticed…again far over to the right, another set of little letters; “b” and “c”. Note “c” on the bottom of the page told me that Medicare paid $388.23. There was no clue what that reimbursement of 29% of charges was actually for.

OK, OK, I know that hospital charges and reimbursement are complicated, so I moved along to the physician’s claim summary information. Surely this will be easier to understand.

FTC Proposes New Safeguards for Online Privacy

Dec 2, 2010• 3

By NAOMI FREUNDLICH

Yesterday the Federal Trade Commission proposed a broad framework for protecting consumer privacy both on the Web and offline. The framework is meant to help guide policymakers in crafting legislation to prevent the tracking and wholesale collection and sale of consumer information that is practiced by large online companies like Google, Mozilla, and Microsoft. Yesterday I wrote about health information “data mining;” (see post here) the collection and sale specifically of web user’s health data, including the conditions they suffer from, medications used and identification information like name, age, gender and even personal doctor. As the FTC notes in its proposal; “The more information that is known about a consumer, the more a company will pay to deliver a precisely-targeted advertisement to him.”

The FTC noted that current privacy efforts by most online companies were inadequate. Some did not alert consumers to the fact that data was being collected in the first place, others provided lengthy and incomprehensible warnings that most Web users ignore and others did offer the chance for individuals to block collection of their personal data, but this action has to be repeated at the beginning of every transaction.

Instead, the FTC framework proposes a “Do Not Track” option that consumers can chose to activate on their browsers. Similar to a “Do Not Call” list that prevents most (but not all) telemarketers from contacting you by phone, the “Do Not Track” option would prevent most data miners from surreptitiously collecting personal information online. The FTC says that the Do Not Call registry currently contains 200 million telephone numbers.

Publicity is Cheap, Privacy is Expensive

Dec 2, 2010• 2

By JOHN HALAMKA, MD

When I was 18 years old, publicity was hard to come by. Media outlets were limited to newspapers with very high editorial standards, television with few channels and very limited news time, and a few high profile news magazines.

My first 15 minutes of fame came in 1981 when I was interviewed by Dan Rather for a CBS Evening News spot on entrepreneurialism in the Silicon Valley. In 1982, I appeared in Newsweek, as a student correspondent at Stanford, writing about religion, politics and the culturally important trends of the day. In 1983, I appeared in US News and World Report in an article about the emerging importance of software.

Today, blogs, wikis, forums, YouTube, Facebook, Twitter, and Google enable fame and publicity without editorial control. Use your phone to take a video of a squirrel doing something amusing and a few minutes later you’ve got publicity and thousands of people watching your work.

The Non-Scalability of Charisma

Dec 1, 2010• 19

By BOB WACHTER, MD

Early on, many social movements depend on a charismatic leader to focus attention, build a burning platform, and inspire people to action. You know when the movement has made it when it no longer needs such a leader for fuel.

The safety and quality movements have picked up tremendous steam over the past decade, but they haven’t yet hit that self-sustaining tipping point. Last week, there were two things that reminded me of this: the announcement of a new leader of the Institute for Healthcare Improvement (IHI), and a doleful JAMA essay by Peter Pronovost.

During the circus that was Don Berwick’s recess appointment to lead the Centers for Medicare & Medicaid Services (CMS), all eyes were trained Inside the Beltway. But 440 miles north, in Cambridge, MA, arguably the most important organization in the quality and safety galaxy needed to get on with its business. On July 8th, IHI announced its choice of Maureen Bisognano to become its new CEO. Maureen is a nurse and former hospital exec who has spent the last 15 years at IHI as Don’s consigliere. She is a terrific person, with boundless energy and great organizational skills – insiders will tell you that she was the reason that IHI’s trains ran on time for the past decade, as Don is the quintessential big picture guy.Continue reading…

The Conservative Way Forward on Health Care

Dec 1, 2010• 75

By RICHARD AMERLING, MD

The landslide Republican victory, in taking the House and electing some strong conservatives to the Senate, can be interpreted as a mandate to rein in government spending, and specifically to repeal ObamaCare, as these issues were clearly behind the large turnout. There is still a very real possibility the Supreme Court will find the “individual mandate” to buy private insurance unconstitutional. If this provision is thrown out, it’s hard to see how the law survives, since the mandate is needed to finance it.

Now is an excellent time to construct a conservative alternative vision for true reform of our health care delivery system. Since most current problems with the health care system stem from government, a conservative plan should seek to reduce its role.

It goes without saying that the Patient Protection and Affordable Care Act must be repealed since, like all the laws passed by this administration, it does precisely the opposite of what its name suggests. By massively increasing the health care bureaucracy at the expense of actual providers of care, it will make care harder to access and more expensive. Many physicians will take early retirement and the already great physician shortage will be exacerbated.

Are prescription drugs going the way of Napster, YouTube and iTunes?

Nov 30, 2010• 2

By DAVID E. WILLIAMS

The distribution of prescription pharmaceuticals is beginning to take on some of the characteristics of online videos and music. Traditionally, access to prescriptions works as follows:

Patient has a problem
Patients sees his/her physician
Physician diagnoses problem and writes prescription
Patient takes prescription to traditional pharmacy or PBM-owned mail order company
Pharmacy fills prescription with a drug manufactured by an FDA-regulated brand name or generic pharmaceutical company
Patient takes medication
If patient needs more medication after initial prescription and refills are exhausted, patient requests renewal from physician and repeats steps 4 to 7

But steps 2 through 7 are breaking down. Instead of seeing their physicians, increasing numbers of patients are either going directly online to order from pharmacies or are borrowing pills from friends and family who’ve received prescriptions. According to MedPage Today (Adults Commonly Share Prescription Drugs with Friends and Family) almost 30 percent of adults reported sharing prescription medications with others. Younger people are the most likely to share.

Meanwhile, shady web-based pharmacies that don’t require prescriptions and often sell counterfeit drugs are becoming increasingly sophisticated and impressive. MarketMonitor estimates that about 1000 shady pharmacy sites generate an average of 100,000 hits per day each and that such pharmacies spend about $25 million per year on search advertising. An acquaintance who works in the pharmaceutical security business told me that these pharmacies aren’t what they used to be. In fact they are adopting marketing and customer service best practices that are used by legitimate vendors. Rather than going for a quick score, the web-based companies are looking for repeat business and word-of-mouth referrals by providing products that work, offering easy-to-navigate websites and low prices.

The preview of the Health 2.0 Accelerator Apps Network is now available on video

Nov 29, 2010• 1

At the Fall 2010 Health 2.0 Conference
seven companies demonstrate composite applications
to connect and support patients, caregivers and providers.

San Francisco, November 10, 2010 – The preview of the Health 2.0 Accelerator Apps Network is now available on video – showing 7 interoperating health sites and composite applications – at http://www.health2con.com/2010/11/11/health-2-0-accelerator-group/.

The Health 2.0 Accelerator Apps Network is a growing ecosystem of web applications and services that work together – collaborating 2, 3, 4 and more at a time, serving as platforms for other apps and as interoperable bridges between apps – all to connect and support patients, caregivers and providers. This year's preview was presented at the Fall 2010 Health 2.0 Conference, during the "Tools and Unplatforms Part II: the Emerging Consumer-Centric Ecosystem" session, (www.health2con.com) moderated by Matthew Holt, Co-Founder of Health 2.0. Following the presentation, the Health 2.0 Accelerator companies discussed the process of working together to build these connected and composite applications and how others can join the network.

In his role as Lead Architect of the Health 2.0 Accelerator, Erick Von Schweber explained the architecture and standards the group is using to enable these powerful but relatively easy to implement integrations. Enhanced Medical Decisions facilitated data interoperability by retrofitting deidentified free text medical records with the addition of interoperable codes, transforming misspelled drugs to NDC medication codes and user entered symptom descriptions to ICD-9 condition codes and thus supporting action on standard data forms.

The Cost of Success

Nov 29, 2010• 6

By ROB LAMBERTS, MD

For those of you who didn’t know, I entered the National Novel Writing Month “contest” (which has no winners). I got to the goal of 50,000 words yesterday.

One of the main questions that is asked in my novel (which may or may not ever see the light of day) is this: What would happen if a wonderful cure came along that would take away most, if not all sickness? Remember, it is fiction.

The answer is, of course: utter chaos and collapse of our system.

Our system is designed to deal with sickness. It is designed to fix problems. If a wonder-drug came along, here’s what I think would happen:

Pharmaceutical companies and hospitals would have to oppose it, as they would suffer financial ruin if people became healthy.
Doctors, especially those focused on chronic illness or treatment of serious problems, would take a huge cut in pay.
A huge number of healthy people would enter the workforce, disrupting an already fragile economy.

Human stupidity, of course, would remain. There would be some work for those in the medical profession, but only a fraction of what is there now.

SF 2010: Keynote Address from Jeff Goldsmith

Nov 29, 2010

By Bianca Grogan

Jeff Goldsmith, President, Health Futures, Inc., gave a keynote address at the Health 2.0 Fall Conference in San Francisco, CA on October 7-8, 2010. Since the 1970s he’s worked in academia, in government, advised virtually every major health care delivery, insurance and supplier organization, been a national advisor to Ernst & Young, and is on the Board of Health Affairs. On the main stage Jeff spoke about transforming our health care system and the problems and challenges that we face.

The Ryan/Rivlin Plan

Nov 29, 2010

By JOHN GOODMAN, PhD

Congressman Paul Ryan (R-WI) and Alice Rivlin, former director of the Congressional Budget Office (CBO), have proposed an entitlement spending reform plan that is striking both for its boldness and its left-right-coming-together origins. There are a number of interesting parts, but I want to focus on the three most important:

Medicare would, for the first time, be transformed into rational insurance. Beginning in 2013, all enrollees would be protected by a $6,000 cap on out-of-pocket expenses; in return they would pay for more small expenses on their own.
After a decade, people newly eligible for Medicare would receive a voucher to purchase private insurance instead. The value of the voucher would grow at the rate of growth of GDP plus 1% (note: for the past four decades, health care spending per capita nationwide has been growing at about GDP growth plus 2%).
Medicaid would be turned into annual block grants to the states. The value of the block grants would also grow at GDP growth plus 1%.

Bottom line verdict: This is a good proposal that deserves serious attention. To guarantee its success, however, more needs to be done to (1) allow the private sector to control costs through economic incentives, competition and entrepreneurship and (2) allow young people to save for the growing share of expenses they will be expected to bear.

How Does This Plan Compare with the Affordable Care Act (ACA)? Given that Ryan has been previously attacked by Paul Krugman and others on the left because of his ideas about voucherizing Medicare, a natural question arises. How does the Ryan/Rivlin slowdown in Medicare spending compare to the health reform bill Congress passed last spring — a bill supported by some of the very people attacking Ryan?